What is retrospective review?

Retrospective review is the process of determining coverage after treatment has been given. These evaluations occur by:

• Confirming member eligibility and the availability of benefits
• Analyzing patient care data to support the coverage determination process
• Receiving supporting clinical documentation from providers with the payment request

When retrospective review is available

Retrospective review is available when:

• Precertification/notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim.
• Aetna converts from secondary payer to primary payer at the time of inpatient claims adjudication.

Retrospective review is not available when claims are for:

• Elective ambulatory or inpatient services on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List for which precertification did not occur before providing the service
• Emergency inpatient services on the previously mentioned precertification lists that did not meet notification requirements (notification of inpatient admissions is required within one business day of the admission date)
• Services not included on a precertification list
• Services that do not require precertification under the terms of a member’s plan

Find precertification lists

The retrospective review process

The retrospective review process includes:

• The identification and referral of members, when appropriate, to covered specialty programs, including Aetna Health Connections^SM case management and disease management, behavioral health, National Medical Excellence Program^®, and women’s health programs, such as the Beginning Right^® Maternity Program and the infertility program.
  
• The identification and referral of potential quality and/or utilization issues for follow-up
• The identification, referral and review (as applicable) of patient safety events

Retrospective review does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider.